Customer Service Medical Claims
Resume:
Professional Profile
Career Objective
To obtain a healthcare related customer service role that utilizes my skills and experience.
Personal Profile
I have worked in the health insurance industry since 1993. I obtained an internship at American Medical Security while I was a Business Administration student at S. Norbert College and I have held various positions in claims and customer service. I also have experience as a Business Process Analyst. I have obtained a technical diploma in Medical Coding as of December 2016.
Skills Summary
Medical Claims Processing
Extensive phone customer service skills
Business Project Analyst skills
Root cause analysis
Expertise in handling difficult customer interactions
Process improvement skills
Organizational skills
Extensive experience making independent decisions and judgements
Critical analysis skills
Medical Provider Correspondence Processing
Customer Service Representative Auditing experience
Providing mentoring and guidance to less experienced associate
Caseload management experience
Excellent written communication skills
Medicare and Medicaid claims knowledge
Medical claims coding knowledge (CPT, HCPCS, ICD-10)
Claims Research and Resolution Professional- Humana Inc., October 2015 to present
Resolve escalated medical claims disputes that involve all aspects of medical claim billing and processing including billing errors, code editing issues, contracting issues, and system configuration issues, communicate with providers verbally and electronically to resolve escalated claim disputes, collaborate with Contracting and Sales Market associates to resolve ongoing claims issues for providers, provide education to providers regarding medical claims billing. Respond to providers with written and verbal communication. Work with team members and associates from other departments to identify trends in claims processing errors. Provide suggestions for role process improvement or updates required to training guidelines. Build and maintain relationships with key providers for Humana.
Correspondence Specialist- Humana Inc., August 2005 to October 2015
Process provider submitted correspondence. Respond to providers with written and verbal communication. Work with team members and associates from other departments to resolve provider inquiries in a timely and efficient manner. Manage a workload of inquiries so that they are handled efficiently and timely. Provide suggestions for role process improvement or updates required to training guidelines.
Business Process Analyst- Humana Inc., October 2003 to August 2005
Managed projects for claims legacy system process improvements. Brainstormed process improvement ideas with team members. Obtained management approval to proceed with projects. Reported back to management with project status updates. Worked closely with information technology associates to communicate the needs for claims processing from the business perspective. Worked with trainers and processing guidelines associates to incorporate the changes in to training and guidelines. .
Customer Service/Internet Enrollment Specialist- Humana Inc., October 2001 to October 2003
Assisted agents and group employer contacts with enrollment in the Emphesys web-based insurance plan. Handled claims related calls transferred from first line customer service representatives. Resolved member, agent and provider inquiries related to the web-based product. Worked with a team to resolve customer inquiries.
Customer Claims and Correspondence Specialist- Humana Inc., October 1996 to October 2001
Handled claims written and verbal inquiries. Resolved claims related correspondence by responding to providers and members with letters or claims adjustments. Answered second level claims and benefits calls. Worked with a team to resolve customer inquiries.
Customer Service Representative Mentor/Auditor- American Medical Security, October 1995 to October 1996
Worked with a team to design and implement a process for monitoring customer service representatives on the phones in order to audit and provide feedback to them regarding their performance. Recorded verbal customer inquiries. Audited verbal customer inquiries. Held meetings with customer service representatives regarding their customer service performance and provided recommendations on how their performance could be improved. Designed auditing forms. Submitted feedback to customer service supervisors regarding associate performance on the phones.
Claims Processor and Customer Service Representative-American Medical Security, September 1993 to October 1995
Processed medical insurance claims and took claims related phone inquiries
Education
NORTHEAST WISCONSIN TECHNICAL COLLEGE
Medical Coding Technical Diploma
December 2016
ST. NORBERT COLLEGE – De Pere, WI
Bachelor of Business Administration 1993
MARQUETTE UNIVERSITY- Milwaukee, WI
Business Administration major 1989-1991
GREEN BAY PREBLE HIGH SCHOOL – Green Bay, WI
1989
Special Skills
Ability to type 65 words per minute
Proficiency in Microsoft Word and Excel
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